Eyeworld

132 | EYEWORLD | JULY 2021 G UCOMA A positive Seidel test indicating the presence of a late-onset bleb leak (15 years postoperatively), a complication of trabeculectomy that requires immediate management to prevent the development of infection Source: Kateki Vinod, MD by Liz Hillman Editorial Co-Director About the physicians Constance Okeke, MD Assistant Professor Eastern Virginia Medical School Norfolk, Virginia Kateki Vinod, MD Assistant Professor of Ophthalmology Icahn School of Medicine at Mount Sinai New York Eye and Ear Infirmary of Mount Sinai New York, New York Infection and MIGS Dr. Okeke said there is a paucity of literature evaluating infection rates with MIGS proce- dures, but she thinks the rate is low in her clin- ical experience. She compared the rate as likely similar to that of endophthalmitis in cataract surgery, which she put between 0.13–0.7%. "I have not seen any increase in rates of infection with my cataract surgeries because the majority of my surgeries are combined [with MIGS], and I've had rare instances of endoph- thalmitis in my surgical cases. I think the infec- tion rates for MIGS procedures are likely similar to cataract surgery." Another change that could be impacting in- fection rates for the better is intracameral anti- biotics. Dr. Okeke said she began using intraca- meral antibiotics with her standalone MIGS and combined cataract surgery procedures within the last 4–5 years. If an infection did occur after a procedure that included MIGS, she said it is handled in the same way it would be if it had occurred after cataract surgery alone. "I have never had an experience where a patient had endophthalmitis and it was needed to remove a device or stent. … Just like with cataract surgery, the implant stays in the eye, but you treat the infection," Dr. Okeke said. Infection and incisional glaucoma surgery While MIGS avoids some of the complications associated with incisional glaucoma surgery, tube shunt and trabeculectomy procedures are still a mainstay for glaucoma patients who need dramatic pressure lowering. They also carry a higher risk for infection. Kateki Vinod, MD, explained that trabe- culectomy, tube shunts, and the XEN Gel Stent (Allergan), which has been described as MIGS plus and is still bleb-forming, cause disruptions in conjunctival integrity, which can present pathways for pathogens to enter the eye, even years after surgery. She noted that while endophthalmitis rates associated with these fil- tering surgeries are low, they tend to be higher I nfection is a risk for any ocular surgery, but in general, Constance Okeke, MD, thinks there are a few reasons why there isn't a lot of discussion about infection when it comes to glaucoma procedures. MIGS, which have become increasingly common, have a lower in- fection risk profile compared to incisional glau- coma surgery. In addition, traditional glaucoma surgery (tubes or trabs) now have enhanced techniques that may reduce infection risk even in these procedures. "I don't see a lot of infection in surgery that I do in glaucoma," Dr. Okeke said. "I do think it has a lot to do with the reduction of trabeculec- tomies that I have done over the course of the last decade and the increase in MIGS proce- dures, either standalone or combined with cat- aract surgery. I do not see incidence of infection in any way increased, but decreased." Infection and glaucoma surgery

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